Varney, Arthur OF QUEEN,5BUr�
PLNE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURy, NEW YORK 17804
(518) 745-4476 (518) 745-4477
/ Funeral Director �u��et��,
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Da i t o Of Crema t i.on Oc+0 b
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Time Cremation Started L U
Time Cremation Completed
Type of Container
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Remarks
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Town of Queensbury
Pine View Cemetery and C remaknium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Office.: (518)745-4476, Crematorium: (518)7454477 '
Audxmization to Cremate
The undersigned request and n isW n rtaes Pine View Crerfw*odum,in a000rdenoe with arw std*d to its Rules and Regulations to
cremate the remains d:
Arthur Frederick Varney M
(Name) (Sear)
5.51 Lower Oak Street Fort Edward NY 12828-
(Street) (City) (State) (Wp Code)
who died on 18th day of October 2D07
at Glens Falls Hospital Glens Falls NY
(Place) (Address)
Nam and address of a- no IWhV Mk***or name of permn authorb"cremation:
Arlene Varney 551 Lower Oak Street, Hudson Falls, NY 12839
(Nam) (Addrew)
Retetlonship to the depeased Wife
Name ofFtmaraiFkxv Carleton Funeral Home, Inc.
IMPORTANT:
i represent diet to the beet of my k%wAedge,the 0105) InID) ,debbrNOW,beft Y,battery tom,pmw
cell,redioective implant or radioecdve devioa in his or her body.
I oar*that i have U power and eWrori¢stlon ID am pe for the cremalbn of the remelt end to direct the disposition of the
cramated remains,that any perem posse-in m have eid a beard removed or maybe destroyed,and agme to protect,defend and
save hon+ttasa Pine Vk%v Crsmokmttm►from any and aN rinirrts and dernerids for toss or damages which maybe made against them
by d or carnamd wkh the cremation of said nwakts as directed,whedw suit claims ar rim- 'art Je are or erg not wholy
false ar baufWert.
68 Main Street, Hudson Falls, NY
(Address)
55 Lower Oak Street Hudson Falls, NY 12839
(Signature end Address or t egai Representative)
Signed an this date: ?0/ z t ( U
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated rernetns es ftlows:.
Mail to
Other arrangements'Please spaclry:
If pAveraetion of cremated remains is mWested,deck here XX
Revwarx April 18,2007